Denial Code CARC 96: Non-Covered Charges

CARC 96 means the payer treats the service as non-covered under the member’s plan. It is worth examining rather than accepting, because non-coverage is sometimes a mis-applied benefit, a plan-specific exclusion that does not actually apply, or a service that is covered when billed to the correct benefit, medical instead of dental.

What this denial means

The payer is saying the member’s plan does not cover this service. The paired remark code usually cites the specific plan provision or exclusion.

Why it happens

It may be a true exclusion. But it is often a benefit mismatch: the service is covered under the medical benefit but was billed to dental, or a plan-specific exclusion was applied that does not fit the situation, or the service is covered with a condition (a diagnosis, a site) that was not established on the claim.

The appeal angle that works

Read the remark code to see exactly which provision was cited, then check whether the service is covered under a different benefit. Dental work inextricably linked to a covered medical condition is the classic case: denied under dental, covered under medical. Rebill to the correct benefit with the linkage documented rather than appealing the dental denial on its own terms.

Questions

A service was denied as non-covered. Could it still be paid?

Sometimes, yes. Non-coverage is often a benefit mismatch rather than a true exclusion. Dental work that is inextricably linked to a covered medical condition, for example, may be denied under the dental benefit but covered under medical when billed correctly with the linkage documented.